Episode 67: Radiologic Imaging & Hernias | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Welcome everyone. Today is another Tuesday on Hernia Talk. Tuesday. You’re with me live. My name is Dr. Shirin Towfigh. Thank you for following me on Facebook at Dr. Towfigh where this is a Facebook Live and also of course on YouTube. Many of you will be watching it there. Thanks Also for those of you that follow me on Instagram and Twitter at hernia doc, so today is going to be fun day. We’re going to be talking about radiology. Of course, if you have any other hernia related questions, you let me know because I’m here to answer your questions. All I live in breathe hernias and I’m always so grateful that so many of you log in and have fun with me with this radiology topics, I mean hernia topics. However, I thought we would spend some time on radiology. Now, let me just preface, I am not a radiologist.

Speaker 1 (00:01:05):

I am not trained in officially in radiology. When I was a resident, I really enjoyed radiology and where I trained at UCLA, we were very much encouraged to read our own imaging even though we’re not radiologists, we’re surgeons. And we had amazing radiologists. Dr. Barbara Kadell, who I believe is still there, was one of my idols there. And she was at that time a very seasoned surgeon. I believe she’s still there teaching, but man, she was amazing at reading CAT scans. And if I had a patient that had a CAT scan, I would physically go down to radiology with the imaging. And back then we had these, the actual films, and then she would put it up on those lighted boxes and she would read it, but she wouldn’t just tell you what the answer was. She would kind of show you like, okay, see here, this is what I’m seeing, et cetera. So I learned a lot from her. That’s Dr. Barbara Kadell and she’s got a great story.

Speaker 1 (00:02:16):

She was among the more senior radiologist, and actually being a radiologist back then was as a female was not common. And at the same time, she became the strongest and most respected in her department. So that really strong lady, I really admired that. Anyway, in addition, I started doing mostly hernia surgery and we started to learn that MRIs are something that are very useful in the diagnosis of hernias. And I did that because when I came to Cedar Sinai after about six years out of training, I started working with a radiologist. Her name is Dr. Rola Saouaf. She’s like the head MRI specialist at Cedar Sinai. And she really taught me how much more information we can get from an MRI as opposed to the typical imaging that we do for hernias, which is ultrasound number one and CAT scan number two. So in most of the world, except for the United States, ultrasound is the dominant imaging modality for hernias for abdominal wall or for the groin.

Speaker 1 (00:03:30):

Because it’s cheap, it doesn’t require any radiation, no, anyone can do it if they know what they’re doing with the ultrasound and it’s readily available throughout most of the world. In the United States, we tend to do much more CAT scans in general, not just for hernias, but in general. And doctors especially ER doctors and surgeons are much more comfortable with the CAT scan and how to read it than ultrasound and MRI. So CAT scans are fairly fast to perform. It’s like you go in there couple minutes at the most, if there’s any preparation for it, that may take some time. But we have a lot of CAT scans in the United States. I mean in this one mile block I’m probably probably like, I’m going to guess, but it’s going to be like maybe 30 CAT scans is ridiculous. So that’s the United States bent. No CAT scans in general are more expensive.

Speaker 1 (00:04:37):

It’s like a big machine. You need a technologist to be able to run it. Usually a radiologist themself doesn’t know how to run it, and then there’s a lot of, other accessories that go with it. It’s expensive. You got to turn on turn off. It’s very labor intensive, but over time it’s become very cheap to provide CAT scan service and very rapid and it gives you so much more information than an ultrasound. Now you may not need the information and a really good ultrasonographer can possibly recreate that, but in the United States, we’ve lost the art of ultrasonography in general surgery and really rely heavily on cat. So most surgeons in training and surgeons in practice are very comfortable reading a CAT scan for most things. And so if you have a hernia or a bulge or abdominal wall issue, a CAT scan tends to be what gets ordered in the United States.

Speaker 1 (00:05:41):

And then when I was working at Cedar Sinai, initially I met with Dr. Dr. Saouaf and she’s like, if you considered MRI and really no one was doing MRIs back then, it was not a common thing. But MRI, the skill of MRI is that, or the benefit of it is that it’s really good for soft tissue. So it differentiates the soft tissue differences. Muscle fat skin, it’s not the best for intestines, which is what most general surgeons are interested in, like gallbladder, liver, pancreas, intestines. It’s not considered first line for most of those. However, for soft tissue like lipomas, lipo, sarcomas, sarcomas, any tumors of the soft tissue, that’s why breasts is also now doing MRIs. Anything that relates to the fat and the muscle, any sports injuries, orthopedic injuries, MRI is really, really helpful because it gives you a lot of detail about the muscle and its surrounding tissues.

Speaker 1 (00:06:49):

So people started using MRIs for sports-related problems like athletic pubalgia and sports Hernias and so on. And Dr. Saouaf was like, well, we should consider developing a protocol for you for hernias. And that’s where my MRI hernia protocol came about and we’ll discuss that shortly. But then I started sitting down with her because we didn’t really do much MRI education in general surgery residency, and I was very uncomfortable reading MRIs. I would kind of understand it, but not really. So I would sit down with Dr. Saouaf, every single patient, I’d sit down with her. I didn’t just read the report and just believe the report. I would sit down with her and I would say, what about here? What about there? And she would teach me. And I had examined the patient, I knew the patient, I knew exactly what to look for the patient.

Speaker 1 (00:07:39):

And so I also was able to add to Dr. Saouaf’s or the radiologist’s education and knowledge base to kind of tell them what we look for in hernias. What do I want to know about the Mesh? I want to know how it’s related to the spermatic cord. I want to see if the Mesh is involving the bladder or the vessels in the groin. There’s MR Neurography where you can look at the nerves and so on. So it was a very nice mutual friendship. And then I got to know other radiologists around my town and they started developing the same MRI hernia protocol, which is now throughout most of Los Angeles County. And when I see patients that are from out of town, I do encourage them to ask for the MRI hernia protocol, which we have. So again, I’m not a radiologist. I’m not going to be able to give you this amazing talk about everything you need to know about radiology.

Speaker 1 (00:08:42):

But for hernias, I’ve learned to be really good. And so almost every patient that I see who’s had imaging, I read it myself. So ultrasound, CT, MRI, I look at the report, but often I rely on my own interpretation. And many of you have questions about that. Do the radiologist find everything? And we noticed as I was reading my own MRIs and CAT scans and ultrasounds, I know I noticed that what I saw and what was reported was very different and what I operate on and what was reported was very different. So we’re going to go through that data. I’m going to share with you my own experience. We’ve published on it, I’ve written chapters on it, I’ve given talks, and you guys don’t come to our surgical meetings, so you don’t have the option to get to hear those. And many of you don’t read surgical literature, which is actually out there.

Speaker 1 (00:09:45):

So if you want, it’s all on the internet, but I will share with you that data so you have a better understanding of what it means to kind of go through the motions of hernias and so on. So based on that, let’s go through your questions. And I know that you’re very interested in this because I got tons of questions for this. I think I got about 20 through Instagram, hernia talk.com, emailed to me. I’m really, really excited to go through these. So let’s go through these one by one and if you have your own questions, please share and we’ll start kind of not too complicated and we’ll get more complicated. So very quickly, what imaging should be used in the diagnosis of hernias?

Speaker 1 (00:10:39):

Number one, ultrasound. Ultrasound is cheap, readily available throughout the world and is considered the basic diagnostic imaging for hernias. That’s groin hernias in the groin area, the inguinal hernias as well as abdominal wall hernias. And we’re talking like you haven’t had surgery yet, so you haven’t had surgery yet. You think you may have a hernia. Ultrasound is a great study. Now is it the perfect study? It’s not, but that’s where I would start for most people. The next level up is a CAT scan. CAT scan involves radiation. You’re really sure to have more than I think 25 or more CAT scans in your lifetime, otherwise your risk of cancer can go up. So we’re very judicious about the use of CAT scan. That said, CAT scan gives more information than an ultrasound for the abdominal wall, so belly button or any kind of abdominal wall hernias because in addition to showing yes or no for hernias, it’ll give me information about what’s going on nearby.

Speaker 1 (00:11:46):

Is there an abscess? Is there a tumor pushing the bowel to go into this hernia? And if there’s Mesh, sometimes you can get a little bit more information on a CAT scan for the abdominal wall. It’ll also show you more information such as a diastasis. Now ultrasound will show you that too, but often when you ask for a hernia ultrasound, they look at only the specific area, whereas if you do a CAT scan, you’re not relying on the person doing the ultrasound to get exactly like what you want. It gives you the full picture. So maybe there’s a tumor on the kidney, maybe there’s a mask growing, like a liposarcoma. All of these will be better identified with a CAT scan because it gives you a bigger picture. Not necessarily more exact picture, but a bigger picture. For example, I had one patient who had a hernia and I got imaging on him and he had a tumor.

Speaker 1 (00:12:43):

He actually had, it was not a hernia. Well, I mean he had a hernia, but what was growing into the hernia was tumor and not like fat or bowel and cetera, et cetera. And so that amount of information before planning for surgery was very, very helpful. And instead of me doing the hernia, I sent ’em to a surgical oncologist colleague of mine and he had the right operation. So couple questions are being asked already. I’m a cancer patient and I have annual PET scans. Are they useful? So yes, again, I’m not a radiologist, but I have friends that are radiologists. So PET scan is different. PET scan has to do with kind of injecting something in your blood system, which is kind of glucose based. And it goes to areas of your body that use a lot of glucose and tumors. Some tumors use more glucose than others.

Speaker 1 (00:13:37):

And so a PET scan can kind of show areas of hyperactivity. Not all tumors show up on PET scan, but it’s a nice way to follow up if for certain tumors and there’s no radiation involved with the PET scan. Now the next question is about nerves. Will they show anything about acne syndrome? So acnes is an acronym, A C N E S. It stands for abdominal cutaneous nerve entrapment syndrome. It’s an entrapment of a nerve and those nerves are super narrow and they only get entrapped with certain muscle activities. So no imaging will show you if you have acne syndrome. It is not. It’s purely a diagnostic diagnosis. It’s a diagnosis that is identified based on your story and your examination and maybe injections. No imaging is helpful for acne syndrome. So we’re talking about what images should be used in the diagnosis of hernias.

Speaker 1 (00:14:42):

And the next tear up is MRI. Now, MRI is not widely available throughout the world. It tends be available only in kind of, I would say richer countries. It’s very expensive, millions of dollars for a machine. You need a highly specialized technician to be able to run the MRI and it takes forever to get one done. It can be 20 minutes, 40 minutes over an hour depending on the protocol used. So the benefit is there is no radiation involved with MRI. So for example, if you’re pregnant, it’s very safe to have an MRI and it’s often used instead of a CAT scan for that purpose.

Speaker 1 (00:15:28):

The drawback of MRI, it’s very difficult to read. It’s very complicated. It’s like different shades of gray. And depending on the protocol it may give you some information, but not all information. So not all MRIs are the same. And then the institutions, like the big hospitals and the university-based institutions tend to have the higher level MRIs. It’s like HD, like 4k, like the three Tesla or higher. And then the typical outpatient areas which are not as rich and can’t afford to buy the higher definition, MRIs tend to have a lower definition. MRIs, one and a half Tesla and all that makes a difference.

Speaker 1 (00:16:18):

Reading MRIs is very difficult. Most surgeons are very uncomfortable reading MRIs for hernias. That’s just because it’s not part of our training and it is complicated. And so they rely almost a hundred percent on the radiologists interpreting it. And most radiologists are not skilled in reading hernia MRIs, especially if it’s related to a complicated situation like Mesh and entrapment and things like that. So MRI does give much more information for the AL hernias in the groin. In general, for the pelvis, MRI is much better than CAT scan for the abdominal wall. I tend not to use it. It doesn’t really help me that much. It’s much better and less expensive to get a CAT scan for the abdominal wall. So belly button and abdominal wall as opposed to the pelvis and the groin where MRI is much better. So I hope that kind of clears it up.

Speaker 1 (00:17:21):

Basically, ultrasound for most people is fine. CT scan for the abdominal wall and then MRI for the pelvis, especially if you have a complex situation in the pelvis like prior surgery or an occult hernia or something, no one can figure out. And CT scan’s okay for the pelvis. But typically if you already feel a hernia, the CT scan just maybe confirms it, not a good as good, it is not as good for a called hernias. And I have data to show you for that and I’ll go through that shortly. And then another question just posed, but in the same line is what’s the odds of a radiologist missing hernias on either MRI or CAT scan? And I actually looked at that for the groin. So inguinal hernias because that’s, I do a lot of groin hernias and I’ve tended to see mistakes. The reports did not even mention that they looked for hernia or if they did, they said there was no hernia and it was wrong.

Speaker 1 (00:18:26):

And we found that up to three-fourths of imaging was incorrect. Three-fourths, the three and a four up to three-fourths of imaging was incorrect in reporting the diagnosis of hernias. And you know what happens is the patient goes to their doctor, they order ultrasound or CAT scan. CAT scan says either no hernia or doesn’t mention anything about a hernia in the report. Now the image itself will show it if you look for it, but the report doesn’t show it because they weren’t looking for it. Or if they did look for it, they didn’t understand what a hernia is. And so that patient is now labeled as no hernia. And now they go through this whole rigmarole of figuring out what their chronic pelvic pain or abdominal wall pain is from. And years go by and the doctors after doctors, neurologists, orthopedic surgeons, pelvic floor specialists, neurologists, gynecologists, they all look at the report and say, okay, well no hernia, so let’s figure out what else it can be.

Speaker 1 (00:19:27):

Whereas if they could read their own imaging, which is what I’ve learned to do and what I do regularly, you would’ve caught it. So I’ve seen that caught in my patients and therefore save them a lot of time. But it does delay people’s care and it’s kind of a problem. So I’ve taken the time to actually go through a bunch of charts and identify exactly where the problems are. We present, we’ve published our paper twice, two different patient populations, occult hernias and occult hernias. And then also we’ve presented at the R S N A, the Radiologic Society of North America, which is the largest meeting of radiologists. We actually got a research award because we’re there to kind of demonstrate what Mesh looks like and what hernias will look like to radiologists. Cause they don’t know that at the 3D max and the pro, there’s so many different Meshes and Mesh repairs, laparoscopic, robotic, open, PHS, Mesh, those plug, all they can say is, yeah, it looks like there was a hernia repair.

Speaker 1 (00:20:42):

Whereas I would say, oh look, see how this plug is impinging on the bladder or it’s eroding into the spermatic cord or how this plug shouldn’t be here. It should be two centimeters over. So I love it. I love the whole radiology figuring out it’s like puzzle solving, which if any of you are on a hernia attack and have listened to me that I love solving puzzles and I have since I was a kid. So on that note, if you do have this mystery illness or can’t figure things out and you think it may be related to your abdominal wall or hernia or it’s a complication of a hernia repair, I’m happy to review those images for you. You just send me, talk to my office, send me all of those images and your medical records obviously. But I always ask for a CD or a USB or electronic file of your actual image pictures because I’ll review that myself and give you kind of my 2 cents. Now again, I’m not a radiologist. Don’t expect me to find these necessarily some random tumors.

Speaker 1 (00:22:08):

It’s not my specialty. Although I have diagnosed some patients with tumors that required surgery and that was kind of cool and it was missed. How did the radiologist miss it? But anyway, I’m happy to be that person to help figure things out for you because I do enjoy it. I’m kind of weird like that. Or another question proposed is can you see absorbable Mesh and imaging? So depends on the imaging. Absorbable Mesh can be seen until it’s absorbed. So depending on the type of Mesh it takes between several weeks to several years for it to absorb. And so while it’s not yet absorbed, we should be able to see the Mesh on imaging. MRI is the best looking for Mesh. CAT scan is second best and ultrasound is third best. So I hope that’s helpful. All right, let’s go through some more questions that were already sent in.

Speaker 1 (00:23:09):

So oh, can you see Mesh on imaging? Yes. So you can’t see it on ultrasound, but it ultrasound is actually ultrasonic like waves. Sound waves, you’re familiar with ultrasound done for pregnant belly. Sound waves are sent and depending on what sound waves are sent back on, image develops. So the Mesh actually distorts that sound image and prevents you from seeing much else beyond the Mesh. So I personally do not order ultrasound for anyone already has Mesh in them. I don’t feel like it gives me that three dimensional view of what’s going on. There are certain centers, I think Cleveland Clinic may be one of them where they have these highly skilled 3D ultrasound radiologists that have a special interest in hernias and do these high tech, high definition 3D ultrasounds that’s not available most places including around me. So I do not rely on ultrasound for any patient that has a Mesh in them.

Speaker 1 (00:24:22):

CAT scan, it’s a difficult one, so CAT scan can show certain meshes. If you have a gore Mesh or a PTFE based Mesh like the older composites, kugels or kugel patch, those will show right up. It’s like a white line on CT scan can see it very well. Most other meshes including the polypropylene, the polyester and the different absorbable meshes and biologic meshes are not seen very well on CT scan. Technically they’re seen but it’s like a gray scale and the muscle’s also gray, so it’s hard to differentiate between what’s muscle and what’s Mesh. MRI is my favorite study specifically looking for Mesh, especially in the groin because the fat’s white, the Mesh is black, the muscle’s gray, like you can differentiate one from the other. So I tend to err on using CT scan from abdominal wall meshes and MRI for the groin. Pelvic meshes, oh, here’s a hernia question.

Speaker 1 (00:25:29):

Do inguinal hernias in young women in their twenties show up as direct or indirect? Indirect? Actually anyone who’s young, male or female, the most common hernia is an indirect. Direct hernias are not expected in young people unless they have a collagen disorder like Ehlors Danlos syndrome. It’s typically a weakness of the muscles and therefore most people who have direct hernias tend to be older of age. Next question is in an ultrasound, can an enlarged lymph node and a one centimeter inguinal hernia be confused? Okay, typically no. An enlarged lymph node is very clear. It’s round or oval, it has a specific color to it and it doesn’t move. Whereas an inguinal hernia is either fat or bowel, which is not round and it moves, goes in and out. And just remember all hernia ultrasounds should be done is what we call dynamic. So dynamic means there’s a movement.

Speaker 1 (00:26:38):

What I feel happens oftentimes is people are told to lay flat the bed, this examination bed like you’re pregnant and they take the ultrasound and they look for hernia and they can’t find a hernia at the most they may say push out and that’s it. I have a great radiologist that I work with and he loves hernias almost as much as I do. And he does a true dynamic hernia ultrasound. He’ll have you sit up, bend forward, stand up, he’ll have you cough, move your leg in and out, do lots of things to encourage a small hernia to push out, and he does a really good deep exam. And so based on that, I do feel that if you have a good ultrasonographer, you should not have a mistake between a hernia and a lymph node. Sorry about the, they’re like doing construction in my building, however, I can see a situation where the ultrasound technologist, usually not a radiologist in the us, we have technologists that do this where the ultrasound technologist will go ahead and see a bulge and then that gets sent over to the radiologist at different time they’re sitting in their office reading something not in real time and not talking with the patient.

Speaker 1 (00:28:03):

And then what happens is what you understand that, oh, maybe a lymph node, you can’t really tell that really shouldn’t happen. But it does happen a lot. Okay, so going back to that other question, what is the difference between an indirect and a direct from you? So almost all the majority of inguinal hernias in the groin are indirect al hernias. We’re only talking about the groin here. Indirect al hernias are the most common in men. They go down the inguinal canal into the scrotum eventually. And in women there’s a bulge in the groin. That’s the most common. It’s a hole. And through that hole, whatever content goes through, usually fat, sometimes about the direct hernias are not really holes. I mean there can be, but it’s more bulging or a weakness of the muscle. That’s why we see it more in elderly because it’s really a weakening of the muscle or a thinning of the muscle. And if you have that at a young age, it’s because you have a direct hernia because you actually have a muscle or tissue problem. Like a collagen disorder syndrome is the most common even though that’s rare.

Speaker 1 (00:29:26):

All right. Do you guys hear this background with the construction? I’m trying to reduce how much background noise there is, but it’s quite a lot. I apologize for that. It’s what happens when you’re at the office after hours. Okay, next question. An MRI was ordered for me after a year of pain in the same spot. I was told I have no hernia on the CAT scan, I have diastasis recti, shall I move forward with surgery or wait for the MRI? Are there any thoughts? So depends on who you trust and if how good your doctor and radiologist is. Now, if you have diastasis recti and you’re planning for surgery and you have a hernia, they’ll find the hernia and they’ll fix it. So hopefully that shouldn’t be a problem.

Speaker 1 (00:30:27):

Okay, you just told me that the sound’s not that bad, but in my ear it’s like really bad. All right, let me know if it’s too bad. I can’t control the building’s construction. Okay, let’s see. Next question. Do you recommend ultrasound after hernia repair surgery to check the procedure? No, I do not. So I don’t recommend checking hernia repairs like regularly. That’s not something we do. And whatever imaging shows is not something we tend to respond to. We really respond to how you feel after surgery that should spark imaging and not vice versa. And I just mentioned when you’ve had surgery, especially if you’ve had Mesh ultrasound’s not very helpful. And also what’s important is if you haven’t had Mesh, you’re going to have scar tissue regardless. And quite honestly, the scar tissue will also distort the ultrasound. So most people who perform ultrasound are not very comfortable evaluating the groin or the abdominal wall with an ultrasound when there is scar tissue.

Speaker 1 (00:32:11):

All right, next question. If a patient has chronic pain and scans have shown thinning of the muscle, should imaging be performed periodically? If so, how often? Again, no, there’s very little benefit in routine imaging for hernias. We don’t look to see if there get bigger over time because we go by symptoms, we don’t evaluate to see if the muscles are getting thinner. We go by symptoms. Once the diagnosis is identified, it’s often not important to redo imaging. Now there are exceptions to that obviously. So if you have an incisional hernia and you have imaging from five years ago and you feel that it’s gotten bigger and you’re being seen for possible repair, I would want a more updated imaging because I’m going to use that information to plan my surgery. I want to know how wide the hernia is and things like that, how your muscles are, how that’s changed or if you had new surgery. But in general, we don’t recommend repeating imaging. No, they do for cancer, they do that for certain lung diseases, but we don’t usually recommend serial imaging in patients with that have hernia problems.

Speaker 1 (00:33:29):

All right. Should we do more questions? No, it’s like not as much noise in the background. These people are sabotaging my hernia attack if they only knew what was going on the other side of this wall. All right guys, let’s see. Let’s, Jesus, wow, that’s horrible noise. What is your hernia protocol for imaging CT and MRI? Okay, this is good. I’m going to share. Here we go. This is my MRI protocol. You guys can ask for it. From the office I share with all my patients. This is the MRI that I use for all my patients, for their her groin hernia. It’s a pelvic MRI, it’s a non-contrast MRI. So there’s no reason to use any contrast. No iv. No oral. You don’t eat anything, drink anything and you don’t do any injections.

Speaker 1 (00:35:01):

And it’s a dynamic study. So dynamic means, again, movement. We discussed that earlier. So are you pushing things in and out or not? And it’s a very unique protocol because it is dynamic and many people think that you can’t get a dynamic study with a MRI. Totally not true. I do this all the time now it is more labor intensive. So when people have this done, it’s like minimum 45 minutes, sometimes hour and a half to get the whole study because it’s like three imaging in one. It’s a regular MRI pelvis, no contrast. It’s like MRI pelvis with Valsalva, which means a bear down or pushing a view. And then it’s a MRI pelvis video and the video will kind of show small hernias. So if you ask me for this protocol, and I believe it’s on, I think I posted it, I believe it’s posted on Instagram and Facebook and I think even Twitter. So it’s all of these things. T2 Hayes, T2 Hayes with Valsalva, t1, t2, and different types of fat saturations.

Speaker 1 (00:36:21):

So what I recommend is this protocol. Some people call it a sports hernia protocol. It’s not exactly the same, but it’s good enough. The sports hernia protocols tend not to have the Valsalva and the dynamic use, but it’s a lot of imaging but no radiation. But it gives me a lot of information. So if you’re out of town and not here to do the MRI protocol with me, I will send this to you. You will take it to your local imaging place and then they will take that hopefully and work with the radiologist and develop the protocol.

Speaker 1 (00:37:03):

All right, the next question is, hi doctor. Is a hip degeneration also a symptom of Mesh rejection? No, completely unrelated. Next question. Can a scan show issues with the cremasteric muscle after surgery like inflammation? Yes, it has to have a lot of inflammation. A little bit of inflammation is not going to show up on an MRI, but inflammation does show up on MRI, so that’s why I love it. So you can tell the difference between good inflammation and bad inflammation. Scar tissue with no inflammation abscess with information. They’re killing me here. Is this noise like ridiculously loud or what? I may have to end this session early and we’ll do it like another day. I feel like I can barely even hear myself talking. Can you guys give me some feedback as to how much noise you’re hearing? Because if it’s a lot on your end, rather we just do this in a different session, maybe finish the rest of it next week. Give me some feedback if you would on your, as you’re typing it for me, I really want to hear, okay, sounds like it’s acceptable. Alright, if it’s acceptable, I’m going to move forward. If it’s not, you just let me know.

Speaker 1 (00:38:42):

Oh, you hear me clearly? Okay. All right. I’ll move forward. I can barely hear myself. All right, so with regard to a CAT scan, the CAT scan protocol is different. I don’t like to use a lot of IV contrast. It is something that is considered legitimate. Most people do not have blood tests and some people can get kidney injury because of the contrast with the CAT scan. Remember em MRI, you don’t need to contrast, but some people like to give contrast for a CAT scan. I do not. The only benefit of contrast for a CAT scan is if you have an infection or inflammation that you really want to figure out. So I only give oral contrast. You have to drink this thing like hour and a half and then immediately before the imaging and in doing so, the bowel will fill with contrast. And that way what you can do is identify what’s bowel and what’s hernia.

Speaker 1 (00:39:50):

And if it’s all bowel, then in the hernia I can see that if there’s no bowel in the hernia, I can help differentiate and I can see the Mesh and where the bowel is in relationship to the Mesh. And so for CAT scans, I do like to give oral contrast. The other protocol for CAT scans could be to add Valsalva. And one of you had sent me a question which is what is Valsalva a bear down as you’re pushing out, as if you are having a very intense bowel movement or you want to push your belly out so you look pregnant, that’s a Valsalva and we do that to increase or accentuate the amount of pressure in the abdominal wall. So that’s kind of where we are with the CAT scan. So MRI protocol is no contrast. CT scan protocol is with oral contrast usually.

Speaker 1 (00:40:49):

Again, sorry for the distracting noise. I have no control over the co construction in my building and I’m here after hours to help you guys get your questions answered. So thanks for bearing with me. All right, so here was that question about what is the Valsalva. Remember we also talked about ultrasound hernia. Ultrasound should be done with bear down views and Valsalva. So I prefer almost every imaging to be done with Valsalva, although that’s not considered standard, it just gives you much more information. So I do think that bear down views is important. Dynamic study is different. Dynamic is like a movie. They like film things moving as opposed to a bear down view, which is a one time shot of imaging with you pushing out. So that’s the difference between dynamic and Valsalva or bear down. And then, oh, these questions have all been answered. Does oral or IV contrast help with imaging? IV contrast? Almost never unless you have inflammation that you want to look at an infection. And then oral contrast helps with CAT scans but not with MRI and with ultrasounds there’s no need to do either of those. Here’s a great question. Can imaging help identify adhesions?

Speaker 1 (00:42:18):

Technically yes, but practically speaking, no. In other words, MRI and CT scans if done correctly and you have a highly skilled radiologist, they can interpret part of it of like if there’s adhesions or not, especially with Valsalva. MRI enterography is one where they can look for adhesions however, and with ultrasound maybe it’s typically not something that’s identified you to really have to have a close relationship with your radiologist as a surgeon to see if they can kind of interpret that. But technically, yes, they can identify it. All right, let’s go to the next question. I have intense right groin and right testicle pain. Will a urologist be there for the surgery? No. Well assuming the general surgeon’s doing the hernia repair. So if the groin pain and the testicle pain are due to a hernia, then typically the hernia surgeon will do the repair and a urologist will not be there. If there’s a need for a urologist, they may ask urologist to be there, especially if they find a urologic reason for the pain. And if you want more, go to my videos where I discussed testicular pain and male urological problems with Dr. Paul Turek and Dr. Houman. Both of them are kind of male fertility specialist and we had a whole session about that on hernia talk. So go to that. You can see it all on YouTube. YouTube.

Speaker 1 (00:44:06):

All right, next question. Let’s see. This is so funny, I just have to laugh. What’s the appearance of this spermatic cord lipoma on MRI? So looks like fat and most spermatic cord lipomas are really not spermatic cord lipomas. They are pre peritoneal fat that the spermatic cord separate from the spermatic cord. So if you see the fat near the spermatic cord also alongside the cord and then continuous with the pre peritoneal fat, then that’s what we call the cord lipoma. It’s kind of a misnomer rarely, but it happens. You can have a separate lipoma distinct from the pre peritoneal fat that’s in the groin and if it is, sometimes that’s a cancer, like a liposarcoma and not a true hernia related problem.

Speaker 1 (00:45:06):

And yes, that’s how you identify direct or indirect hernias is based on anatomy. The epigastric vessels are what are the borders of a direct or versus an indirect hernia. A fatty cord has very different looking fat than spermatic cord lipoma much more vascular and that’s how you can tell what’s fatty cord and what’s a lipoma. So these are subtle things require imaging, but things that I may look for especially in a certain patient, but almost never are these things identified as part of your typical imaging. What’s the appearance on MRI of various sports for injuries? Okay, I am not a radiologist, so I’m not going to answer this question the way you probably want, which is very detailed. But just know that you can tell where inflammation is very much better with MRI than any other imaging. And that also you can, there may be even fluid collections because of sports injuries.

Speaker 1 (00:46:19):

Yeah, I hope you go to our YouTube. There’s we had some really good sessions with urologists. Okay, next question. Is gadolinium enhancement useful for diagnosing athletic pathology inflammation? No, we don’t use gadolinium for much except like the brain tumors and it’s almost never useful. Okay, I wanted to share screen with you guys towards the end of this talk on where is it? Here it is. This is my first paper talking about and occult hernias versus non occult hernias. This is published I think 2014. There you go. In Gemma surgery used to be called archives of surgery. And here’s some answers to some of the questions. We looked at 76 patients and they had ultrasound, CT and MRIs and we looked to see how useful these were to identify hernias, inguinal hernias. And what we found was ultrasound had 56% sensitivity. And I’m just going to tell you the difference.

Speaker 1 (00:47:42):

Let’s look here, which is a predictive value. What’s a predictive value of a positive test? What’s a predictive value of a negative test? So for an ultrasound, the positive predictive value is a hundred percent. In other words, if you get an ultrasound and tells you you have a hernia a hundred percent of the time you will have a hernia. It’s correct study. However, if you have an ultrasound and it doesn’t show hernia, that absolutely does not mean you don’t have a hernia and you should move on to the next test. All right, next one, CT scan. These are all people with, these are all people that have a hernia CT scan. If you have a CT scan which shows a hernia, 96% of the time the positive predictive value is correct. In other words, that was a correctly identified study, but if you have no finding of a hernia on CT scan, that may be true only 4% of the time.

Speaker 1 (00:48:49):

The majority of the time when it’s negative, it’s really not negative. And then you have to go to MRI and an MRI. If a MRI says you have a hernia, this is the radiology report, then 97% of the time that is a correct answer. And if it says you don’t have a hernia, so it’s a negative study, the predictive value of that negative study being correctly negative is 79%. So as you can see, the sensitivity and specificity of an MRI for inguinal hernias is super high, 91% and 92%. And that’s why if you order ultrasound and it’s negative, don’t stop there, get a C T scan. If that’s negative, then get an MRI. If they’re all negative, then the likelihood you don’t have a hernia. But then you, here’s the next step is what about occult hernias? So those patients, we carved out the occult hernias to see where the occult hernias are important to identify.

Speaker 1 (00:49:48):

And what we found was it’s even worse with occult hernias. So again, if an ultrasound shows an occult hernia is identified, believe it, you’re done, but don’t believe it. If it’s a negative study, if you get a CAT scan, 86% of the time it will correctly identify a hernia whereas only 6% of the time will it correctly say there’s no hernia. So then look at these numbers for MRI, completely different. The positive predictive value for an MRI is super high, 95% and 85% for negative predictive value. So if you get an MRI and it shows a hernia, 95% of the time they would be correct. And if it shows no hernia 85% of the time, that would be correct. So that’s why the sensitivity and specificity of an MRI for inguinal hernia is 91% and 92%. Sorry for occult al hernias. And this takes me to one of the questions which was submitted earlier, which is this and it’s a great, great question. And that is, where is the question?

Speaker 1 (00:51:06):

Here it is. Here’s a great question and basically it’s this. It says, I went to two different places and got two different ultrasounds. One found a hernia one, which one do I believe? What do we just say? If an ultrasound shows a hernia, believe it. There’s no reason to not believe that ultrasound in hernia. It’s a hundred percent positive predictive value, at least in the patients that I’ve treated. And so you don’t need to redo or not believe the ultrasound one is positive, positive predictive value is a hundred percent. However, the negative predictive value is 0%. So about half the time it’s going to be incorrect. And that’s kind of an important detail about hernias I think go hernias. And so you can read this paper in mine, it’s very detailed and it kind of shows you that if you have a clinical suspicion of a hernia that based on your symptoms and the examination, if the examination confirms a hernia, just get it repaired if that’s what you prefer or get an ultrasound and then to confirm it and then get it repaired. But if you have a non-diagnostic study, sorry, exam, and you may or may not have a hernia, then I tend to go straight to MRI. But you can get an ultrasound or CT scan if that it shows a hernia, go ahead and get it repaired. If it doesn’t show a hernia, then you have to go get the MRI. And that’s kind of what I use to kind of the algorithm that I use based on imaging.

Speaker 1 (00:52:51):

I want to tell you, we kind did a snarky study, we did it with our radiologist. So it’s not like I am being mean to radiologists. Every one of these papers that I’ve published, I’ve done alongside radiologists, but we actually looked at what happens when you compare the radiologic studies, the report of the radiologist versus my radiologist, I’m concerned very versus the surgeon who’s in the OR looking at image at the hernia. So these are all patients that already have hernias. I took ’em to surgery, I confirmed the hernia and I fixed it or maybe I found no hernia, but usually I find the hernia that is like you can’t get more exact than that. Then we went backwards and we took those images from those patients and looked to see what the radiologist report said. And then we also had our own radiologist without knowing anything about the patient blinded review, the same imaging.

Speaker 1 (00:54:01):

So this was published couple years later, 2018 and we, there’s some nice pictures in it, but here’s a cool information. So what we showed was the skilled radiologist that understands hernias, understands Mesh, understands what a hernia will look like, even if it’s super small, it was more likely to identify it does better than your average radiologist that’s reading everything. And so what this table show is that especially in these occult smaller hernias, that a specialty radiologist is more likely to identify the hernia than a non-specialist. So here you are like 71% versus 26% for all imaging looking at CAT scan, it’s 74% or correct versus 24% for a typical radiologist. And then for MRI it’s 65% are correct versus 30% for a non-specialist radiologist. So that was very eye-opening. I kind of knew it, but it was nice to look at the data and get actual details.

Speaker 1 (00:55:24):

And then what we did was we also looked at comparing like how often were they both correct or both incorrect? And it basically shows that the specialty radiologist is almost always better at kind of reading these than the non-special. So this is another paper of mine you can read if you wish. It’s a little bit technical, but the conclusion is that most radiologists, most radiology reports for CT and MRI are incorrect for evaluation of occult hernias. And the specialty radiologist reports are at least twice as much accurate when evaluating the same images and that a physician who is relying on reports alone is inadequately addressing the needs of the patient. So if you have a patient with a good story for groin and pelvic pain due to hernia and you do a radiologic study that’s negative, this might take home message to your eyes if it’s a negative study, but your exam and or your history, it’s consistent with the hernia. Don’t believe the study move on to a much more, more kind of exact study. And really that was the take home message and I hope that that was helpful for you guys. I didn’t want to get too technical With radiology, it’s often over the head of a lot of people.

Speaker 1 (00:57:08):

Oh, here’s a question doctor. I’m a medically uneducated elderly man with undiagnosed and diagnosed bilateral inguinal hernias. How do I question a medical specialist on their protocol or diagnosis? Good question. I do understand that there’s a little bit of hesitancy to question your doctor or seek help. So I publish this stuff, you can share it with your doctors if you feel you’re not able to discuss very frankly with your doctor, find another doctor if you’re in the United States. I always say this, we don’t have socialized medicine. It’s a private and public system. So please go ahead and find another doctor. I’m happy to help you through that process. You can contact my office and I can work with you. I can even work with your own surgeon, give you some guidance, but feel free to show them literature or even ask them. And if you feel like your doctor is very open to fielding questions, great.

Speaker 1 (00:58:08):

If you feel like your doctor’s kind of not very happy about that, then honestly I would see find a doctor that’s maybe a better fit for you. And that’s kind of where I am in terms of my thoughts about, I feel very strongly that you should have a doctor that meets your needs and that includes being able to answer all your questions for you. I’m going to end with one last question, which I get asked a lot and I’m just going to give you my philosophy about what I think about this and then we’ll end this. I need surgery, but I have no insurance. What are my options? All right. First of all, having no insurance doesn’t mean you can’t get care. You can pay cash for it. There’s a lot of people that have cash and they have savings and they get their care that way.

Speaker 1 (00:58:58):

Insurance is not necessary in order to get care. Second of all, if you don’t have the cash or resources to pay for your care and you’d be surprised it’s actually not as expensive as you think, then there are public avenues in the United States and elsewhere for you to get care. So go to your local county or public facility and I recommend you go to one that’s affiliated with a university because they tend to have more specialists available to you than the average kind of county facility. So I hope this all very helpful for you. Thank you for everyone who tolerated the construction. That was crazy. I didn’t like that kind of interrupted me and I wish I had any powers to stop them and have them not work, but work needs to be done. So thanks everyone for joining me. It’s another hernia talk Tuesday. Come back next week. I have some great guests lined up for you. Make sure you watch this and share it on YouTube from my YouTube channel. Thanks to everyone who watched and asked their questions on Facebook Live and on Zoom, I’ll post everything on Twitter and Instagram as well at Hernia Doc. And on that note, goodnight. Sorry about all the noise. We will see each other next week on Tuesday.